Discover if our device is right for you! Answer a few simple questions to see if you qualify, and we'll email you personalized next steps to make getting started easy. This form is confidential.

Please tell us a bit about yourself

First Name

Last Name

Your Email

Your Phone Number

Which State do you live in?

What is your smartphone model?

Do any of the following apply to your affected leg or legs, particularly the area below the knee?

Metal implants under the skin

Cancerous growths or suspected tumors

Recent bone fractures or dislocations

Poor blood circulation, blood clots, or inflamed veins

Active bone infections

Areas of unexplained bleeding or bruising

None of the above apply

Do you have muscle weakness or difficulty lifting your foot when walking?

Yes No

What best describes your current walking situation?

I do not currently walk I walk with an assistive device or orthotic I walk without an assistive device or orthotic

Please select the option that best describes your typical mobility.

Note: If you use a walking aid such as a cane, walker, or similar device, please consider your speed while using it.

I primarily use a wheelchair when outside the house, or I am unable to walk the length of a typical grocery store aisle without significant assistance.

I can walk, but very slowly. It takes me more than thirty seconds to walk the length of a typical grocery store aisle which is about fifty feet or fifteen meters. I often need to pause or take breaks.

I can walk slowly but steadily. It takes me about thirty seconds to walk the length of a typical grocery store aisle. I can usually keep going without stopping.

I can walk at a moderate pace. I could walk the length of a typical grocery store aisle in about twenty seconds. I can maintain this pace for short distances.

I can walk at a fairly normal speed. I could walk the length of a typical grocery store aisle in about fifteen seconds or less. I can maintain this pace for longer distances.

I can walk briskly. I could walk the length of a typical grocery store aisle in less than ten seconds. I have no trouble maintaining this pace.

Do you actively work with a physical therapist?

Yes No Not actively, but willing to work with my Physical Therapist again

EvoWalk Qualification Form